School Nursing Documentation For Continuity of Care

2. Why Document? No one ever looks at our notes� Until they are subpoenaed and then it�s too late! We don�t do head to toe assessments� You should be completing system assessments I see too many students to chart details� The attorney�s and The Board of Nursing does not accept excuses for poor documentation

3. Why Document? Risk Management� Nurses notes are used disciplinary reviews Used in Board of Nursing Reviews

4. Why Document? Professional Accountability� It�s imbedded in the Standards of Professional Nursing TAC - � Rule 217.11

5. Why Document? Legal Document� Entered as evidence in trials Determines if appropriate care was rendered

6. Why Document? Research� Nurses notes serve as a valuable resource for data assessing effectiveness of interventions evaluating outcomes

7. Who Should Document? Those with first hand knowledge

8. What Should I Document? Chief or Presenting Complaint Assessment (system or head to toe) Intervention or Plan of care

9. What Should I Document? Evaluation Time of arrival, parent contact and discharge Where patient was discharged (home, class, etc..)

10. What Should I Document? If applicable, physician�s orders If applicable, contacts with other health team members concerning significant events regarding student�s status

11. Do�s and Don�ts Use black ink Legible writing Don�t leave blank spaces Correct mistaken entries Use approved abbreviations only Document in student�s own words

12. Do�s and Don�ts Document as soon as possible after the event occurred Late entries must be clearly identified If charting electronically, never share your password Document objective findings Don�t document subjective findings

13. Documenting the Assessment Assessment - General When did the problem start? Have they been seen by a physician? What are they doing for the problem? (medications, ointments, etc.) Did they tell their parents/guardian about about the problem?

14. Assessment � Illness Related� Objective description of the symptoms System assessment (i.e. sore throat � pharynx � red, tonsils 2+, lymph nodes not enlarged)

15. Assessment � Injury Related� Objective description of the injury Injury assessment (i.e. left ankle � no redness, swelling noted, good ROM in all directions without complaints of tenderness, good muscle strength, gait within normal limits, no limping)

16. Intervention � Plan of Care� Document care given i.e. Rest Elevated limb on pillow, icepack to ankle Medication per orders

17. Intervention � Plan of Care� Document teaching i.e. Discussed care wound care and signs and symptoms of infection Student to return to clinic after lunch if continues to feel bad

18. Evaluation� Evaluation the student�s response to and attainment of desired outcome from the intervention Document in objective terms the outcome of the intervention i.e. Student reports stomach feels or better swelling and redness decreased

19. Types of Documentation Narrative By exception Problem oriented SOAP/SOAPIE

20. Documentation Examples�

21. What�s Missing? SA. Rested. Back to class.

22. What�s Missing? ASSESSMENT EVALUATION

23. What�s Missing? c/o headache, feeling tired and not well. grandmother notified. requested Tylenol. oral med. administered at grandmother's request. will check on when returns home.

24. What�s Missing? ASSESSMENT EVALUATION

25. What�s Missing? Stomache hurting all morning. Started before school. Actually hurt last night. Took some pink medicine last night. Ate cinnamon rolls for breakfast. Rest No improvement, Called dad, he'll pick up.

26. What�s Missing? ASSESSMENT EVALUATION

27. What�s Missing? Poked self in left eye. Ice.

28. What�s Missing? ASSESSMENT EVALUATION

29. What�s Missing? "I scraped my finger on the field trip." Left pinkie small superficial abrasion. Area washed thoroughly with soap and water, antibiotic ointment and band aid applied, student expressed increased comfort and sent back to class.

30. What�s Missing? NOTHING!!!!!

31. What�s Missing? "I scraped my finger on the field trip." Left pinkie small superficial abrasion. Area washed thoroughly with soap and water, antibiotic ointment and band aid applied, student expressed increased comfort and sent back to class.

32. What�s Missing? Student states he was working out and just feels terrible. Achy all over, HA, weak. Feels warm to touch and cold to himself. Throat started hurting last pm. Is a little red and tonsils are mildly swollen. Rest in clinic and tried to rehydrate. Gave Gatorade and water. Student drank the Gatorade, but not much of the water. Not much better after rest and drink. Student states he is having a lot of allergy issues. Called mom to let her know what we have done and sx. We did discuss that strep does cause some of these sx and she said student does have a tendency to get strep. She states he can come home and rest, she may try to get DR. appt.

33. What�s Missing? NOTHING!

34. What�s Missing? Student states he was working out and just feels terrible. Achy all over, HA, weak. Feels warm to touch and cold to himself. Throat started hurting last pm. Is a little red and tonsils are mildly swollen. Rest in clinic and tried to rehydrate. Gave Gatorade and water. Student drank the Gatorade, but not much of the water. Not much better after rest and drink. Student states he is having a lot of allergy issues. Called mom to let her know what we have done and sx. We did discuss that strep does cause some of these sx and she said student does have a tendency to get strep. She states he can come home and rest, she may try to get DR. appt.

35. What�s Missing? Student c/o earache, Backache, HA, SA sore throat, and neck ache. Can easily touch chin to chest without causing more pain. Throat is red and some tonsilar swelling, more pronounced on R side. SWG. Helped some . Rest in clinic. A little better. Does not want to go home. Back to class.

36. What�s Missing? NOTHING!

37. What�s Missing? Student c/o earache, Backache, HA, SA sore throat, and neck ache. Can easily touch chin to chest without causing more pain. Throat is red and some tonsilar swelling, more pronounced on R side. SWG. Helped some . Rest in clinic. A little better. Does not want to go home. Back to class.

38. What�s Missing? Student states she has a "very bad sore throat". rates pain a 7 on 1-10 pain scale. Unable to fully visualize throat. Elevated temp. Describes pain in throat as swollen feeling and it hurts to swallow. SWG done. Student reports it really didn't help. Attempted to call dad. unable to reach. Student will go back to class. Instructed her to return if she is feeling worse or if she wants to try dad again.

39. What�s Missing? NOTHING!

40. What�s Missing? Student states she has a "very bad sore throat". rates pain a 7 on 1-10 pain scale. Unable to fully visualize throat. Elevated temp. Describes pain in throat as swollen feeling and it hurts to swallow. SWG done. Student reports it really didn't help. Attempted to call dad. unable to reach. Student will go back to class. Instructed her to return if she is feeling worse or if she wants to try dad again.

41. Yes, good documentation is more lengthy and time consuming� But, it�s your license and lively hood at stake.

42. Can you remember what you did two years ago or eighteen years ago? I can�t. Remember what�s not documented is not done!